- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $6,165.95
| Professional | | $891.25 | $1,023.29 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $3,981.07
| Professional | | $1,548.82 | $1,737.80 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,238.72 / $2,818.38
| Professional | | $1,412.54 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $6,309.57
| Professional | | $891.25 | $1,548.82 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,698.24 / $2,511.89
| Professional | | $891.25 | $1,698.24 | $2,511.89 |